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Asked to describe medical journals to somebody unfamiliar with them, you probably wouldn't say that they are full of stories. But they are, as this issue shows.
The first story tells of attempts to improve the treatment of people with arthritis, but, as with most good stories, there is a subplot that hints at wickedness. Non-steroidal anti-inflammatory drugs (NSAIDs) have long been used to treat the inflammation of arthritis (p 1289). They do this by inhibiting an enzyme called cyclo-oxygenase that is needed for the production of prostaglandins. Unfortunately the same process operates in the stomach and causes harm. Then it was discovered that there were two sorts of cyclo-oxygenase, one more important in joints and the other in the stomach. By inhibiting the one important in joints it should be possible to enjoy the benefits of treating the arthritis without harming the stomach. So COX 2 inhibitors were born and are now widely used.
But one reason they are widely used is because of a misleading trial
published in JAMA (p
1287). This seemed to confirm in reality what was expected from
theory
COX 2 inhibitors
had fewer gastrointestinal side effects than NSAIDs. But more
complete and longer term data available to the Food and Drug
Administration contradicted these results. The authors had departed
from the protocol of their study, which, as readers of the BMJ
know, will often allow you to find whatever results you want. The
flaws in the study were publicised in JAMA, the BMJ,
and elsewhere, but, argue our editorialists, the study is much better
known than its criticisms. Thirty thousand reprints have been
distributed, the study is highly cited, and sales of the particular
COX 2 inhibitor have grown from $2623m (£1800m) in 2000 to $3114m in
2001.
A second story is short and poignant (p 1314). A patient waiting for an operation suffered a caustic burn after being given not local anaesthetic eye drops but phenol drops. The drops came in similar bottles. The BMJ is keen to share mishaps like this in the hope that it will help minimise them. Please send us examples.
The BMJ is also keen to publish examples of improvement like this
week's third story. Authors from Princess Royal Hospital in Telford
tell how they have been through three phases in treating patients
with heart attacks with thrombolytic drugs (p
1328). In phase one patients referred directly by general
practitioners were seen in the coronary care unit. The median door to
needle time was 45 minutes. In phase 2 all patients were seen by a
nurse in the coronary care unit but doctors started treatment. The
median door to needle time was 40 minutes. In phase 3 all patients
were seen and if appropriate treated by a "coronary care thrombolysis
nurse." Now the median door to needle time is 15 minutes and 80%
of patients are treated within 30 minutes. The authors tell the
story in more detail than in a conventional scientific paper,
increasing, we hope, the paper's educational value.
Footnotes
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